I have never had a patient who was completely non-compliant. As a rule, the bones are non-compliant, but the muscles and subcutaneous tissues are almost always compliant...I have had a number of patients who chose not to follow my advice. It is quite likely that the problem was with me, not with the patient. I had failed to spend enough time to persuade the patient of the presumed wisdom of my advice or perhaps I had not got to know the patient well enough to understand why the advice would not be attractive. That failure on my part does not justify appropriating a word from the physical sciences to hide behind while blaming the patient.
– Dr. Joseph Sapira, Sapira's Art & Science of Bedside Diagnosis
 
Semantics is a tricky thing. When we think about the meanings of the words we say, the result is often eye-opening. Of course, the truly difficult thing is finding the time—as medical students, we are quickly caught up in acquiring new phrases while climbing the steepest part of the learning curve that has more to do with physical exam skills, diagnostic testing, and evidence-based medicine than grammar, phrasing, or double-meanings. Learning to speak the sometimes archaic language of the body and its diseases is one of the skills that sets medical professionals apart from the lay public, but this heedlessly indoctrinated vocabulary can be harmful to our patients and ourselves.
 
Take, for example, the concept of compliance. Originally a term from physics for describing how a specific substance relates volume and pressure, compliance is now used to assess whether or not the patient is following doctor's orders. Although putting the patient in the backseat with the doctor refusing to let go of the wheel is unsettling, the danger truly comes when someone is labeled “non-compliant.” That patient is now often viewed as subversive, stubborn, or unwilling to listen—an embodiment of a waste of time and resources.
 
I started thinking about the how much I dislike the term compliance in regards to patients on rounds last week. When the resident presented the new patient, there was “a question of compliance.” She had brought her bulging bag of full pill bottles, but her diagnosis was directly related to not taking her medicines yet again. Leading the already frustrated team into the room, the doctor leading rounds said, “We are not getting at the heart of the problem. Let's talk to her.” She began a gentle discussion with the patient, not about the need for her to take all these pills, but about how hard it is to be a single mom. How much she receives a month and where the money goes. What her kids like to do. Who puts out her medicines and how many times a week she forgets. How her appointments are all over town. Why she says she doesn't trust her doctors. How she thinks her disease is affecting her body and one thing she would fix. Some of her answers surprised us but more importantly, gave us insight into who she was. We understood a little bit how the pressures of being a single mom have squeezed out her ability to care for herself with a chronic disease in a difficult health care system. We left, initial plan in place, labels forgotten.--Helen Prevas, MS IV

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Medical Student Reflection I: Reflections from the Hallway

by Academy of Clinical Excellence on February 29, 2012

Fourth year Johns Hopkins medical student, Helen Prevas, just completed a 2 week elective offered by the Miller-Coulson Academy of Clinical Excellence. During her time, she shadowed many of the member physicians in their clinical settings. Through a series of blog posts, Helen documents some of what she learned and witnessed during her elective.

As medical students, we witness incredibly personal moments in the name of developing into excellent doctors—from births to hospice visits to code status discussions. So it was surprising to me that after four years, Ms. C was the very first patient to request me to leave the exam room. Her doctor’s “one-liner” outlined Ms. C’s full recovery from a serious illness and her residual anxiety, not always medical-related, that responded to much more frequent visits to the office than any protocol prescribes. Although she welcomed me into the room with her doctor and gave only some hints at underlying worries, it was not until the physical exam portion that Ms. C drew the line. She was apologetic but firm: this conversation was for her and her doctor, alone.
I respect patients’ wish for privacy, and even more, respect the doctors who earn and keep that special trust. There is something in the sitting and listening quietly while someone shares their deepest fears. But how can we hope to reach that point? Her doctor gave me her perspective on establishing the doctor-patient relationship. She said, “I learn about the social stuff, I learn them inside and out as a person. The medical part comes afterwards.” I have heard this sentiment repeatedly from members of the Academy for Clinical Excellence who are adored and trusted by their patients. Sometimes, it is more important to write the names of all the grandchildren in the chart, to know golf handicaps, to remember favorite sports stars than to recall blood pressures, lab numbers, or medication lists. While I did not personally get to know Ms. C, she has taught me more by what I did notdirectly observe and had to infer from my place in the hall, outside the room containing her and her doctor. From the initial visit to the ones fifteen years later, the foundation for a doctor-patient relationship is ultimately a human connection based on listening, sharing, humor, the desire to know our patients as people, and above all, earned trust.
--Helen Prevas, MS IV

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Helping to Allay Patient Fears

by Academy of Clinical Excellence on September 13, 2011

Medical grand rounds resumed this week, signifying the start of another academic year that will be filled with learning and professional growth.
As has become tradition, our Chairman Dr. Hellmann was the first speaker and the talk was entitled "A Nurse with an Enigmatic and Chronic Illness". Along with the help of the patient and her sister, Dr. Hellmann recounted the experiences of a 62 year old woman who suffered for months with fatigue, weakness, and myalgias. We learned that she is a nurse, a talented painter, a world traveler, and a devoted wife, sister, mother, and grandmother.
Before coming to Dr. Hellmann, she had been seen by multiple physicians who were unsure what was going on. Dr. Hellmann established that she had Granulomatosis with Polyangiitis (formerly called Wegener’s) and initiated therapy. The patient recounted that one of the unique things that Dr. Hellmann did that other providers had not was to ask her to think about her ‘goals for care’. At one of her visits, the patient brought with her the following written goal: “To lose fear of the disease and the treatment”.  
As a result of the humanism, education, access, and attention that she has received through her care, the patient explained that her fears have been allayed and that she feels as if she and her physician have taken back control over the illness.

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Another Reason to Counsel Patients to Exercise

by Academy of Clinical Excellence on August 9, 2011

A friend sent me this article from the Montreal Gazette about a 93-year-old man who has exercised vigorously throughout his whole life. When counseling our patients to exercise (http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html ), we often emphasize the benefits on weight and cardiovascular health, however this article describes how important exercise has been in reducing stress and maintaining the mental health of this particular individual.

 

 

Disclosure: Sol Levine is my grandfather.

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Deliberate Practice

by Academy of Clinical Excellence on August 4, 2011


A colleague sent me this interesting article, Composition 1.01: How Email Can Change the Way Professors Teach. It describes how Whittier-Ferguson, a Professor of English at the University of Michigan, is using email to help his students become more proficient writers.

Through the use of emails, Professor Whittier-Ferguson is giving his students feedback in real time as they are composing their writing assignments. This feedback from the expert in real-time while the student is "practicing" their writing creates the teachable moment at just the right time for growth.

This careful observation coupled with specific feedback is at the cornerstone of deliberate practice.

In clinical medicine, engaging in deliberate practice (with observation and feedback to trainees and colleagues) may be easier than doing so in writing. Nonetheless, this piece has prompted me to reflect about innovative and better ways of doing this.


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Compassion When Treating Substance Users

by Academy of Clinical Excellence on July 29, 2011


“You encourage people by seeing good in them” – Nelson Mandela[1]

I know that science doesn’t always inform public policy.If so, high schoolers would begin their day later than elementary school children; cursive writing would be taught before print; syringe exchange programs would be the rule instead of the exception; preventive health care would be a right instead of a privilege, etc.So why was I so surprised when I saw billboards popping up along Baltimore’s highways proclaiming “DUI Is for Losers”?(Don’t believe me, see images of the entire campaign for yourself here http://integrateddesignscorp.com/duiloser.html)

Now, don’t get me wrong I’m against drunk driving as much as the next person.No, that’s a lie.I’m against it more than the next person since I’ve seen firsthand the destruction of life and property it’s wrought.Firsthand.And I treat substance-dependent men and women, many of whom have been charged with DUIs at some time in their life.I’ve heard their compelling and, often, tragic stories of loss.I know that driving drunk can cause unimaginable heartache and irreversible consequences.

But ad campaigns that focus their efforts on stigmatizing individuals with substance use disorders rather than the behaviors themselves aren’t productive.I’ve seen several patients who have accidentally killed their loved ones while intoxicated, and been incarcerated for their crimes, but who nevertheless continue to drive drunk.If that degree of loss and consequence doesn’t motivate someone to change, no loss or consequence will.

All parents have heard the adage: “Criticize the behavior, not the child.”The same holds true for clinicians treating individuals with substance use disorders.Behavioral science teaches us to stigmatize the behavior we want to change, but to build up and motivate the individual to change.[2]I assure you that people with substance use disorders have more than enough self-loathing; they don’t need any more from us.In fact, an individual’s negative self attitude and hopelessness only sustains substance use.So name-calling, which is the basis of the “Loser” campaign above, and focusing on “loss and consequences” (http://www.mica.edu/News/Students_Develop_Campaign_to_Curb_Drunk_Driving_Statewide.html) is a misguided strategy to promote change and will be unproductive at best and counterproductive at worst.

What works to motivate change?Helping individuals find positive, rewarding, self-esteem boosting behaviors that can compete with the substance use.Positive “reinforcements” like education, employment, exercise, substance-free recreational activities, and the realization that theirs is a life worth living.We can play a role in this realization and, guess what, it’s not by name-calling and shaming. It’s by recognizing that NOT having a substance use disorder is an unearned privilege and showing compassion towards those who do.

[2] Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K.Cochrane Database Syst Rev. 2011 May 11


Margaret S. Chisolm, MD

Assistant Professor

Department of Psychiatry and Behavioral Sciences

Johns Hopkins University School of Medicine

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The Hopkins Psychiatry Approach to Patients

by Academy of Clinical Excellence on July 26, 2011


This year, for the first time ever, the Department of Psychiatry and Behavioral Sciences has been ranked #1 in the country by U.S. News & World Report.To appreciate why this is such an important achievement for our department, a little historical context is needed.

Since 1980, the Diagnostic and Statistical Manual (DSM), which categorizes mental conditions based on their outward appearances – the signs and symptoms they produce – has reigned as the dominant classificatory system for psychiatric conditions in the U.S.Since 1980, Hopkins Psychiatry has steadfastly viewed the DSM system as fundamentally flawed and has consistently expressed concern about its negative impact on the field.Hopkins Psychiatry has strongly advocated for the clinical utility of an alternative approach built on concepts developed by Adolf Meyer and Karl Jaspers in the early 20th century (and later articulated by Paul McHugh and Phillip Slavney in The Perspectives of Psychiatry (1).

The Hopkins Psychiatry, or Perspectives, approach presumes that different psychiatric disorders have different natures (e.g., schizophrenia and anorexia nervosa are fundamentally different in their origins) and stresses that understanding the brain will not lead to a causal understanding of all mental illness since many psychiatric disorders are not the result of a broken brain. This approach emphasizes the importance of taking a thorough and detailed history in order to appreciate the full context of an individual’s psychiatric distress.For over three decades, the Perspectives approach has been used to teach Hopkins medical students and residents how to formulate and treat patients with psychiatric disorders.Over 100 peer-reviewed journal articles and book chapters have used this approach in a substantive way, however it has not yet been widely adopted by other institutions for use in patient care or teaching.This recognition by U.S. News & World Report helps us move U.S. psychiatry towards a more personalized and systematic approach for the diagnosis and treatment of our patients

 

[1] McHugh PR, Slavney PR. The perspectives of psychiatry: Johns Hopkins University Press Baltimore, MD; 1998.

Margaret S. Chisolm, MD
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine

 

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The Sad State of Psychiatry

by Academy of Clinical Excellence on July 5, 2011

Marcia Angell’s recently published two-part series on psychiatry in the New York Review of Books (“The Epidemic of Mental Illness: Why” http://www.nyrb.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/and “The Truth about the Drug Companies” http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry ) is a serious indictment of contemporary psychiatry.Although, not every statement Angell makes nor every conclusion she draws about the field is entirely accurate, the essays contain more wheat than chaff, which doesn’t speak well for the sad state of psychiatry.

In reviewing three books (Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch; Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker; and Unhinged: The Trouble with Psychiatry – A Doctor’s Revelations about a Profession in Crisis by Daniel Carlat), Angell’s first essay highlights the dramatic changes in the apparent prevalence of psychiatric disorders as evidenced by increasing psychiatric disability claims, number of individuals in psychiatric treatment (sharply up for children), and psychiatric medication sales.All of this data, although – in part - alarming, is relatively straightforward and undeniable. I vehemently share her concern about the rise in individuals receiving disability for treatable mood disorders.I would add that disability payments can then make certain co-occurring illnesses (such as substance use disorders) more difficult to treat, creating even more disability.Angell’s discussion of the relationship between the pharmaceutical industry and the FDA vis a vis the outcomes of randomized controlled efficacy trials (RCTs) contains some truths, but I do not conclude, as she does, that these trials demonstrate that antidepressants are no better than placebo for the treatment of depression.The complexities of psychiatric RCT design, especially regarding inherent problems with diagnostic criteria (which she addresses, in a different context in the second essay), make me doubt that these medications have no efficacy for certain patients carefully diagnosed by a clinician as moderately or severely depressed.Angell does a great job, however, discussing the role of the placebo effect in trials and – in general – I agree with and applaud the essay’s questioning, skeptical tone regarding the “epidemic” of psychiatric disability and medication sales/treatment.

In her second essay, Angell adds another book to her review, the disturbingly influential Diagnostic and Statistical Manual (DSM).She takes on this “bible” of psychiatry, which she clearly sees is cozily cradled by the arms of Big Pharma.Her understanding of the origin of the DSM (designed to ensure reliability in psychiatric research) and its major weaknesses (its lack of empirical validity and intentionally atheoretical approach met to sidestep the internecine war within psychiatry) is sharp and insightful.And Angell recognizes the impact on individuals and society of such a scientifically and intellectually flabby checklist-approach to psychiatric diagnosis.

To those of us who trained in psychiatry at Johns Hopkins, Angell’s critique of the field is all too familiar.Since the launch of DSM-III in the 1980s, the psychiatry department at Hopkins has consistently and publicly challenged the DSM’s categorical approach to patient formulation.We have witnessed the harmful effects of the ascendancy of the DSM on our field, including the creation of a generation of psychiatrists who no longer routinely conduct a thorough psychiatric evaluation for each patient.It’s now a rare psychiatrist who takes stock of an individual’s life story, intelligence, temperament, and behaviors before reducing the origin of the patient’s complaint to brain disease.

By contrast, at Hopkins we have remained committed to a measured, systematic approach to the psychiatric evaluation of each and every patient.Although we recognize the time-consuming nature of such an evaluation, we also know that it’s essential to the practice of psychiatry.Only by taking a thorough history and performing a complete mental status examination on every patient is a psychiatrist able to understand each patient as an individual.And only by understanding the whole patient, can a clinician develop a comprehensive and personalized treatment plan. This systematic and robust approach, based on The Perspectives of Psychiatry by McHugh and Slavney, allows the clinician to transcend the criteria-based nature of the DSM.The Perspectives approach ensures the consideration of many possible biological and psychological origins of a patient’s distress.

Although DSM-V is on the horizon, critics like Angell are giving voice to concerns shared by many, including those of us at Hopkins, about the state of psychiatry.We encourage such public conversation to continue as there is a clear need for questioning the state of contemporary psychiatry.I hope that other psychiatrists will join us as we continue to advocate for a more personalized and systematic diagnosis and treatment approach for all patients.

Margaret S. Chisolm, MD
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine

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Emotional Lability After Stroke

by Academy of Clinical Excellence on June 8, 2011


I was seeing L back in the office for the first time since he had suffered a stroke.Now age 55, he had suffered with complications of diabetes mellitus since the age of seven. Despite the development of retinopathy, neuropathy and renal failure leading to a kidney transplant, he had remained upbeat, motivated to take care of his health and most importantly he always found joy in life. Today he was clearly different.

The stroke had caused a large bleed in the right side of his brain.His wife had called 911 after he had fallen from sudden left sided weakness. Initially she thought he was hypoglycemic, but his glucose was fine.Soon after arriving in the emergency room, he became obtunded and required intubation and placement on a ventilator.Miraculously, he started to steadily improve over the next 72 hours and was extubated.He quickly regained strength and was able to walk.He improved so quickly that he decided (with my support) not to go to a rehabilitation hospital, but rather to go home and receive home physical therapy.

So here he was before me with tears in his eyes and I did not know how to understand them. We had walked from the waiting room to my office together and his gait was amazingly normal.We had chatted while walking and he had appeared his old self.Once he sat down, his eyes had swelled with tears.I let him regain his composure and he finally explained.

Since returning home from having the stroke, he had started having vivid recollections of childhood events.Several were triggering crying spells. One event, however, was dominating his thoughts as if it had happened the day before:

“I am four years old and helping my mom and dad decorate the Christmas tree.I dropped a light bulb and somehow it sparked. Within a few seconds, there was a fire and the tree and all the presents underneath it were in flames.My dad put out the fire, but all the presents were destroyed.I had ruined everybody’s Christmas.I was heartbroken.My mom and dad tried to reassure me that it was not my fault and that they were not angry with me.I couldn’t stop crying for days.But now here I am over 50 years later and I can’t stop crying over this event that all of sudden seems like it occurred yesterday.”

It was clear that somehow the stroke had activated this painful memory and made him have uncontrolled crying.He denied feeling depressed. We talked more that day and later that afternoon I scoured the literature looking to find out if there were descriptions of this happening after a stroke.Sure enough, there were several reports of post-stroke pathological crying attributed to “stroke-induced partial destruction of the serotonergic raphe nuclei in the brainstem or their ascending projections to the hemispheres.” However, I could not find an explanation as to why he was having such a vivid recollection of a distant memory, as most stroke patients indeed have memory difficulties.

I called him about a week later and discussed with him what I had found. He related that he was getting better gradually and was no longer crying quite as much. He felt even better as we discussed emotionality being common after a stroke. Now we are working on getting him back to work. I am sure he will succeed.

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On Humility

by Academy of Clinical Excellence on June 3, 2011

Humility. The art of detachment, the virtue of method, and the quality of thoroughness may make you students, in the true sense of the word, successful practitioners, or even great investigators, but your characters may still lack that which can alone give permanence to powers—the grace of humility.

As the divine Italian, at the very entrance to Purgatory, was led by his gentle master to the banks of the island and girt with a rush, indicating thereby that he had cast off all pride and self-conceit, and was prepared for his perilous ascent to the realms above, so should you, now at the outset of your journey, take the reed of humility in your hands, in token that you appreciate the length of the way, the difficulties to be overcome, and the fallibility of the faculties upon which you depend.

In these days of aggressive self-assertion, when the stress of competition is so keen and the desire to make the most of oneself so universal, it may seem a little old-fashioned to preach the necessity of this virtue, but I insist for its own sake, and for the sake of what it brings, that a due humility should take the place of honour on the list.

- Sir William Osler

 

A perspective piece, titled "On Humility", appeared in the Annals of Internal Medicine in August. It provides some food for thought on what it means to be clinically excellent. It can be found here.


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